Directions:Please complete and click the "Submit" button.

Yes No Have you attended UNC-Pembroke as a RALC student (Regional Alternative Licensure Center).

If the answer is yes, please continue with this form. However, if the answer is no, contact the Licensure Office located in the School of Education, Room 101A.

Last Name First Name Middle

Student ID:

Date of Birth:
Marital Status:
Permanent Address:


Local Address:
Home telephone:
Work telephone:
Preferred email contact:
Check One of the following:
Licensure Only
Lateral Entry
When do you plan to return to UNCP?
Summer I
Summer II





Ethnic Background
American Indian or Alaskan Indian
Caucasian (Not of Hispanic Origin)
African American (Not of Hispanic Origin)
Asian or Pacific Islander


Please give name, address and current assignment in the public school currently employed. However, if you are not currently employed in a public school, please indicate inserting N/A in the required fields.
Name of School:
Current Teaching Assignment:
Have you attended UNC Pembroke before? Yes No
If you answer yes, please list date previously attended and the name used at the time.

All students must comply with the North Carolina immunization laws. Returning students that fail to demonstrate compliance will be cancelled from their classes and withdrawn from the university. Please contact UNC-Pembroke's Student Health Services

Campus Safety Questions
Your "yes" answer to one or more of the following questions will not necessarily preclude your being admitted. However, your failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw your admission, or to dismiss you after enrollment.
For the purpose of the following six questions, "crime" or "criminal charge" refers to any crime other than a traffic-related misdemeanor or an infraction. You must, however, include alcohol or drug offenses whether or not they are traffic related.
  • Have you been convicted of a crime?
Yes No
  • Have you entered a plea of guilty, a plea of no contest, a plea of nolo contendere, or an Alford plea, or have you received a deferred prosecution or prayer for judgment continued, to a criminal charge?
Yes No
  • Have you otherwise accepted responsibility for the commission of a crime?
Yes No
  • Do you have any criminal charges pending against you?
Yes No
  • Have you ever been expelled, dismissed, suspended, placed on probation, or otherwise subject to any disciplinary sanction by or university?
Yes No
  • If you have ever served in the military, did you receive any type of discharge other than and honorable discharge?

Yes No
Currently serving
Never served

If you answered "yes" to any of the six questions above, please explain the circumstances below.
I understand that I will not be eligible for licensure recommendation from UNC Pembroke with the Regional Licensure Plan of Study.
I UNDERSTAND THAT WITHHOLDING INFORMATION requested in this application or giving false information may make me ineligible for admission to/or continuation at The University of North Carolina at Pembroke. With this in mind, I certify that the statements herein are correct and complete. I understand my failure to provide complete, accurate, and truthful information on this application will be grounds to deny or withdraw my admission, or dismiss me after enrollment.
You must check one of the boxes to the right in order to be considered a readmit student. This will serve the same purpose as your written signature.
Yes, I accept
No, I can not accept



This publication is available in alternative formats upon request. 
Please contact Disability Support Services, DF Lowry Building, 521-6695.

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